CLAIMS, APPEALS & COMPLAINTS

Insurance companies can be selective when it comes to paying for benefits. If you find that you are facing obstacles accessing your treatment and benefits, don’t wait to take action – get started now.

Outlined below are a series of general steps you can take to ensure that your insurance company will cover the treatment you need.

Prior authorization is when your health insurance plan requires approval for certain medical services or treatments before the services or treatments are rendered. Not all services require prior authorization.

Step therapy is a requirement that less costly and less risky treatment alternatives be explored and deemed unsuitable before more uncertain or expensive therapies are approved.

Receive treatment
(Prescriptions or Medical Services)

Every time a service is rendered, either the medical provider or you must retroactively file a claim for the payment of service, providing the insurance company with detailed information about the services you received.

If your insurance company denies your claim

If you reach your benefit limit or lifetime cap

Make an appeal and request a re-evaluation of a claim or service that your insurance company denied. An initial denial is not final and may be overturned if you appeal.

Apply for a limit override if there is sufficient medical need or petition your plan to consider a higher level of coverage.

File a grievance if your claim is denied because the service or products are specifically not covered by your health plan.

You also can file a grievance as a formal complaint (either to your insurance company or an outside regulatory body) regarding any aspect of the services provided by your healthcare plan.

PHA is proud to be able to make educational materials and programs like these available for free to everyone because of the generous support from members of the community just like you. Donations are welcome!

The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.